Medicare Diabetes Prevention Program (MDPP) Expanded Model - Presenter(s): December 5, 2017 - CMS.gov
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Medicare Diabetes Prevention Program (MDPP) Expanded Model
December 5, 2017
Presenter(s):
Amanda Van Vleet
Arielle Zina
Disclaimer
This presentation was current at the time it was published or uploaded onto the web. Medicare
policy changes frequently so links to the source documents have been provided within the
document for your reference.
This presentation was prepared as a service to the public and is not intended to grant rights or
impose obligations. This presentation may contain references or links to statutes, regulations,
or other policy materials. The information provided is only intended to be a general summary. It
is not intended to take the place of either the written law or regulations. We encourage readers
to review the specific statutes, regulations, and other interpretive materials for a full and
accurate statement of their contents.
2Acronyms
Below is a list of acronyms used frequently throughout this presentation.
Acronym Description
CDC Centers for Disease Control and Prevention
CDC DPRP Centers for Disease Control and Prevention Diabetes Prevention Recognition Program
National DPP National Diabetes Prevention Program
CMS Centers for Medicare and Medicaid Services
CMMI Center for Medicare and Medicaid Innovation
MDPP Medicare Diabetes Prevention Program
NPI National Provider Identifier
PFS Physician Fee Schedule
3Agenda
Objectives 5
Context and overview of MDPP services 6
Key upcoming dates 8
MDPP policies finalized in the CY17 Physician Fee Schedule 9
MDPP policies finalized in the CY18 Physician Fee Schedule 10
Helpful resources and information 23
Evaluation 24
Question and answer session 25
4Objectives
Our primary objectives for today’s call are outlined below.
1. Enhance awareness of the MDPP expanded model set of services
2. Increase knowledge and understanding of the MDPP policies finalized in the CY18 Physician Fee Schedule final rule
3. Provide additional resources and address questions related to the MDPP expanded model
5Context
MDPP services respond to high rates of type II diabetes among older Americans.
Problem MDPP Services Impact
25% of Americans 65 years and older Health behavior change sessions Promotes healthier behaviors for
are living with type II diabetes, which furnished by coaches with the goal eligible Medicare beneficiaries that
negatively impacts health outcomes of weight loss could prevent or delay type II diabetes
Care for older Americans (65+ years) CDC-approved curriculum delivered
with diabetes costs Medicare in person to beneficiaries with an Decreases healthcare costs
$104 billion annually, and is growing indication of prediabetes associated with diabetes
6Overview of MDPP Services
MDPP services are offered over a two year period and are intended to prevent the onset of type II diabetes.
Months 0-6 Months 7-12 Months 13-24
Core Sessions Core Maintenance Sessions Ongoing Maintenance Sessions
• MDPP suppliers must offer a minimum • MDPP suppliers must offer a minimum • MDPP suppliers must offer monthly
of 16 sessions, offered at least a week of 6 monthly sessions during the maintenance sessions for an additional
apart, during the first 6 months second 6 months 12 months
• Sessions are available to eligible • Sessions are available to eligible • Eligible beneficiaries who achieve and
beneficiaries regardless of weight loss beneficiaries regardless of weight loss maintain weight loss and attendance
and attendance and attendance goals have coverage for 3 month
• MDPP suppliers must use a CDC- • MDPP suppliers must use a CDC- intervals of monthly maintenance
approved curriculum to guide sessions approved curriculum to guide sessions sessions for up to 1 year
• MDPP suppliers must use topics from
a CDC-approved curriculum to guide
sessions. Session topics may be
repeated. 7Key Upcoming Dates
Key upcoming dates related to the MDPP services rollout are highlighted below.
Prospective MDPP supplier applicants and coaches may obtain National Provider Identifiers (NPIs) at any time
November December January April
2017 2017 2018 2018
CMS final rule MDPP Help MDPP Supplier Suppliers begin
published Desk goes live enrollment begins furnishing
services and
billing Medicare
8MDPP Policies Finalized in the CY17 Physician Fee Schedule
The first cycle of MDPP rulemaking impacted the following policies in the CY17 PFS.
MDPP Services and Description Expansion Authority and Timing
Beneficiary Eligibility CDC Recognition
Supplier Enrollment Coach NPI Requirements
Supplier Revocation Evaluation Requirements
9MDPP Policies Finalized in the CY18 Physician Fee Schedule
The second cycle of MDPP rulemaking impacted the following policies in the CY18 PFS.
MDPP Services and Description Supplier Standards and Compliance
Beneficiary Eligibility Payment Policy
Supplier Enrollment Billing Codes
Beneficiary Engagement Incentives
10Key Policy Changes in the CY18 Physician Fee Schedule
MDPP Services and Description New policy Information added Clarification
MDPP Policy CY17 CY18 Change
MDPP start date • Expanded Model start date • Supplier enrollment begins January 1, 2018
January 1, 2018 • Delivery and billing begin April 1, 2018
New start date
Terminology The CY17 PFS established these The CY18 PFS removed the previous terms and
terms: established the following:
Terms added
• “MDPP core benefit” • “MDPP services” • “MDPP session” and removed
• “MDPP eligible beneficiary” • “Set of MDPP services” • “MDPP beneficiary”
• “Maintenance session bundle” • “MDPP services • “Core maintenance
period” session interval”
• “Core session” • “Ongoing maintenance
• “Core maintenance session interval”
session” • “Make-up session”
• “Ongoing Maintenance • “Virtual make-up
session” session”
11Key Policy Changes in the CY18 Physician Fee Schedule
MDPP Services and Description New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Set of services • 12 month core service period; • 12 months (not 24 months or unspecified) of ongoing
unspecified number of ongoing maintenance sessions if beneficiaries meet weight loss
maintenance sessions and attendance goals, for a total MDPP services period New length
• Additional preventive service; no of up to 2 years
cost sharing requirements
Make-up sessions • No previous policy • In-person
o Must use same curriculum as session missed
o Maximum of one per week; maximum of one per
day of regularly scheduled sessions New make-up
• Virtual session policy
o Same requirements as in-person make-up sessions
o Only by beneficiary request
o Compliant with DPRP virtual standards
o Max of 4 during the core services period, of which
no more than 2 are core maintenance sessions
o Max of 3 that are ongoing maintenance sessions
o Weight loss measurements taken cannot be used 12
for payment or eligibilityKey Policy Changes in the CY18 Physician Fee Schedule
Beneficiary Eligibility New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Eligibility • Enrolled in Medicare Part B • Diabetes diagnosis during the MDPP Services
criteria to begin • BMI of at least 25, 23 if self-identified as Asian Period does not disqualify beneficiaries
MDPP services • 1 of 3 pre-diabetic blood tests • Once-per-lifetime limit: no previous receipt of Criteria
• No previous history of diabetes, except any MDPP services (not just core services) clarified
gestational diabetes
• Must not have end-stage renal Disease (ESRD)
• Once-per-lifetime limit: no previous receipt of
MDPP core services
• Provider referrals are not required
• Beneficiary must have maintained • Beneficiaries must attend at least one in-person core
Eligibility maintenance session in months 10-12 and achieve or
5% weight loss during the previous
criteria for maintain 5% weight loss in months 10-12 to be eligible Addition of
interval to be eligible for the next
ongoing for coverage of the first ongoing maintenance session attendance-
ongoing maintenance session
maintenance interval
interval based
sessions • Beneficiaries must attend at least 2 sessions and eligibility
maintain 5% weight loss within an ongoing maintenance criteria
session interval to be eligible for the next ongoing 13
maintenance session intervalKey Policy Changes in the CY18 Physician Fee Schedule
Payment Policy New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Payment policy • No previous policy • Medicare payments to MDPP suppliers made if
requirements met:
o Beneficiary is eligible New
o Supplier meets all program requirements, requirements
including accepting mandatory assignment
o Sessions furnished by an eligible coach
o Weight loss measurement taken in person
at an MDPP session
o Beneficiary meets attendance or weight
loss goal(s)
o Includes at least 2 sessions per
maintenance intervals
o The supplier is eligible for a bridge payment
14Key Policy Changes in the CY18 Physician Fee Schedule
Payment Policy
MDPP Core Services
Core Sessions Core Maintenance Sessions Ongoing Maintenance Sessions (12 months, 4 intervals)
(6 months) (6 months, 2 intervals)
Interval 1 Interval 2 Interval 1 Interval 2 Interval 3 Interval 4
(Months 0 – 6)
(Months 7-9) (Months 10-12) (Months 13-15) (Months 16-18) (Months 19 – 21) ( Months 22-24)
1 session: $25
2 sessions (with 5% 2 sessions (with 5% 2 sessions (with 5% 2 sessions (with 5% 2 sessions (with 2 sessions (with 5%
4 sessions: $50
WL*): $60 WL*): $60 WL*): $50 WL*): $50 5% WL*): $50 WL*): $50
9 sessions: $90
NOTE: Core session payments are made 2 sessions (without 2 sessions (without 2 sessions (without 2 sessions (without 2 sessions (without 2 sessions (without
regardless of achievement of weight loss 5% WL*): $15 5% WL*): $15 5% WL*): $0 5% WL*): $0 5% WL*): $0 5% WL*): $0
5 Percent weight loss achieved: $160
9 percent weight loss achieved: $25
* WL = weight loss from the beneficiary’s baseline’s weight
15Key Policy Changes in the CY18 Physician Fee Schedule
Billing Codes
May be reported
with Modifier VM
HCPCS G-Code for
Payment Amount Description of MDPP Service (Virtual Make Up
MDPP Services
Session)
G9873 $25 1st core session attended No
G9874 $50 4 total core sessions attended Yes
G9875 $90 9 total core sessions attended Yes
G9876 $15 2 core maintenance sessions attended in months 7-9 (weight loss goal not achieved or maintained) Yes
G9877 $15 2 core maintenance sessions attended in months 10-12 (weight loss goal not achieved or maintained) Yes
G9878 $60 2 core maintenance sessions attended in months 7-9 and weight loss goal achieved or maintained Yes
G9879 $60 2 core maintenance sessions attended in months 10-12 and weight loss goal achieved or maintained Yes
G9880 $160 5 percent weight loss from baseline achieved No
G9881 $25 9 percent weight loss from baseline achieved No
G9882 $50 2 ongoing maintenance sessions attended in months 13-15 and weight loss goal maintained Yes
G9883 $50 2 ongoing maintenance sessions attended in months 16-18 and weight loss goal maintained Yes
G9884 $50 2 ongoing maintenance sessions attended in months 19-21 and weight loss goal maintained Yes
G9885 $50 2 ongoing maintenance sessions attended in months 22-24 and weight loss goal maintained Yes
Bridge payment – first session furnished by MDPP supplier to an MDPP beneficiary who has previously
G9890 $25 Yes
received MDPP services from a different MDPP supplier
MDPP session reported as a line-item on a claim for a payable MDPP services HCPCS G-code for a session
G9891 $0 furnished by the billing supplier that counts toward achievement of the attendance performance goal for the Yes
payable MDPP services HCPCS G-code 16Key Policy Changes in the CY18 Physician Fee Schedule
New policy Information added Clarification
Supplier Enrollment
MDPP Policy CY17 CY18 Change
MDPP supplier • In order to enroll as an MDPP • Suppliers with MDPP preliminary recognition may enroll
eligibility: supplier, organizations require full • MDPP preliminary includes MDPP interim preliminary and
Recognition CDC recognition any preliminary recognition established by the CDC MDPP
• Preliminary recognition deferred to • Created MDPP interim preliminary recognition Standard. Preliminary
CY18 Criteria include at least 60% of participants attend at least recognition fully
9 sessions in months 1-6 and at least 60% attend at least defined
3 sessions in months 7-12. An organization must continue
to follow other CDC DPRP standards.
Enrollment • Established new MDPP supplier • New Medicare enrollment application specific to
application and fee type MDPP suppliers
• Re-enrollment requirement for • Prospective MDPP suppliers must pay fee upon Enrollment
current Medicare providers enrollment application
• High categorical risk screening • Revalidate every 5 years, at moderate risk clarified
• Collect coach NPI and identifying
information
17Key Policy Changes in the CY18 Physician Fee Schedule
Supplier Standards and Compliance New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Compliance with • Suppliers will be revoked if • Established MDPP supplier standards:
MDPP supplier CDC recognition is lost o Excludes suppliers with for-cause Medicaid
standards terminations Established and
o Prevents use of ineligible coaches defined
o Ensures MDPP suppliers are operational standards
o Enables appropriate beneficiary access
o Ensure adequate beneficiary disclosures
o Protect beneficiaries against complaints,
o Supports compliance with the expanded model
evaluation
Coach eligibility • Established eligibility criteria
• NPI requirement
• Ineligible coaches would result in MDPP supplier
• Identifying information for vetting
enrollment denial or revocation, as appropriate.
purposes Use of coach
• In the case of administrative action based on an
ineligible coach, MDPP suppliers have the information
opportunity to submit a corrective action plan to clarified
regain compliance 18Key Policy Changes in the CY18 Physician Fee Schedule
Supplier Standards and Compliance New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Crosswalk • Crosswalk policy described • MDPP suppliers become eligible to submit crosswalk
requirement 6 months after furnishing MDPP services and must
submit at the closest quarter Clarified
• Must continue submitting quarterly thereafter. frequency
Other record-keeping • Suppliers are required to maintain • Clarified that beneficiary information related to MDPP,
and handle any beneficiary PII and including PII and PHI, must be maintained and handled
PHI in compliance with HIPAA as appropriate under HIPAA, other applicable state and Additional
• Must maintain all documents for 7 federal privacy laws, and CMS standards. requirements
years • Upon first session, records must include: added
o Organizational and beneficiary information
o Evidence of beneficiary eligibility
• Upon every additional session, records must include:
o Type of session
o NPI of coach leading the session
o Date and place of service
o Beneficiaries’ weights
19
• Records must be kept for a 10-year periodKey Policy Changes in the CY18 Physician Fee Schedule
Beneficiary Engagement Incentives New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Beneficiary • No previous • Incentives may be furnished by an MDPP supplier to a beneficiary to whom the supplier is
engagement policy furnishing MDPP services. The items or services furnished as incentives must meet the following
incentives conditions: New policy
o Furnished directly by an MDPP supplier or by an agent of the MDPP supplier, such as a
coach, under the MDPP supplier’s direction and control
o Reasonably connected to the CDC-approved DPP curriculum
o Preventive care item or service or an item or service that advances a clinical goal for an
MDPP beneficiary by engaging him or her in better managing his or her health.
Clinical goals: session attendance, weight loss, long-term dietary change, and
adherence to long-term health behavior changes.
o Not be tied to the receipt of services outside of the MDPP services.
o Not be tied to the receipt of services from a particular provider, supplier, or coach.
o Not be advertised or promoted; an MDPP beneficiary may be made aware during the
engagement incentive period when they could reasonably benefit from the items/services
o The cost must not be shifted to another federal health care program.
o The cost must not be shifted to an MDPP beneficiary.
20Key Policy Changes in the CY18 Physician Fee Schedule
Beneficiary Engagement Incentives New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Beneficiary engagement • No previous Items or services involving technology furnished as incentives must meet the following
incentives of technology policy conditions:
• May not, in the aggregate, exceed $1,000 in retail value for any one MDPP New policy
beneficiary
• Must be the minimum necessary to advance a clinical goal for an MDPP beneficiary.
• Items exceeding $100 in retail value must:
o Remain the property of the MDPP supplier; and
o Be retrieved from the MDPP beneficiary at the end of the engagement
incentive period. The MDPP supplier must document all retrieval attempts,
including the ultimate date of retrieval.
Documented diligent, good faith attempts to retrieve items of
technology will be deemed to meet the retrieval requirement.
21Key Policy Changes in the CY18 Physician Fee Schedule
Beneficiary Engagement Incentives New policy Information added Clarification
MDPP Policy CY17 CY18 Change
Beneficiary engagement • No previous Suppliers must establish contemporaneous documentation of incentives that exceed $25
incentives policy in retail value that includes at least:
• The date the incentive was furnished. New policy
• The identity of the MDPP beneficiary to whom the item or service was furnished.
• Documentation establishing that the item or service was furnished to the MDPP
beneficiary during the engagement incentive period.
• For items or services that are used on an ongoing basis during the engagement
incentive period, including items involving technology exceeding $100 in retail value,
documentation must establish that the MDPP beneficiary is in the engagement
incentive period throughout while using the item or service
• The agent of the supplier who furnished the item or service, if applicable.
• A description of the item or service.
• The retail value of the item or service.
• The MDPP supplier must retain and provide access to the documentation.
22Helpful Resources and Information
There are many resources available to support organizations interested in becoming an MDPP supplier.
About MDPP Medicare Enrollment/NPIs Billing/Claims
• MDPP website • Enrollment: PECOS • MAC jurisdictions
• CDC DPRP • NPIs: NPPESIn
standards
If you cannot find what you are looking for:
mdpp@cms.hhs.gov
23Thank You – Please Evaluate Your Experience
Share your thoughts to help us improve – Evaluate today’s event
Visit:
• MLN Events webpage for more information on our conference call and webcast presentations
• Medicare Learning Network homepage for other free educational materials for health care
professionals.
The Medicare Learning Network® and MLN Connects® are registered
trademarks of the U.S. Department of Health and Human Services (HHS).
24Question and Answer Session
There will now be an opportunity for a live question and answer session.
If you have questions that are not addressed during today’s call, please submit
them to mdpp@cms.hhs.gov
25You can also read
